FITNESS INSTRUCTOR. Insurance Program and Enrollment Form This brochure is valid for effective dates from 1/1/16 through 12/31/16 ELIGIBLE OPERATIONS

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1 FITNESS INSTRUCTOR Insurance Program and Enrollment Form This brochure is valid for effective dates from 1/1/16 through 12/31/16 PROGRAM DESCRIPTION This insurance program has been specifically designed to meet the unique needs of a U.S.-based personal training, exercise, aerobic or yoga/pilates instructor directly supervising an individual or group engaged in fitness and exercise activities. Coverage is provided by a carrier rated A+ (Superior) by A.M. Best Company. This program does not provide coverage for the operation, ownership or maintenance of a fitness, sports or dance facility. For information regarding coverage for a facility, please call us. INELIGIBLE OPERATIONS ELIGIBLE OPERATIONS A U.S.-based instructor age 18 or older conducting private or group instruction for any of the following is eligible to enroll in this program: Acrobatic/partner yoga Acro dance/tumbling Aerial/anti-gravity/ suspended yoga (certified instructors only) Aerobics Aquatic exercise Cardio kickboxing Children s fitness programs Dance Exercise Fitness bootcamp GYROTONIC Hoop fitness Personal training Pilates Qigong Spinning Strength Tai Chi Tumbling (floor only, no gymnastic apparatus) Yoga ZUMBA Operations not eligible for this program include, but are not limited to the following: Certified athletic trainers Coaching of organized competitive athletic teams Instructors under the age of 18 Instruction of sports skill activities* Instructor s employment as an exempt or a non-exempt employee of a school, university or college FOUR EASY WAYS TO ENROLL FOR COVERAGE WEB Receive coverage immediately by purchasing online at OR Submit this enrollment form, with payment, to us. programs@ascensionins.com * Information and applications for sports instructor insurance are available at or by calling our office. FAX MAIL Regular: Ascension Benefits & Insurance Solutions P.O. Box Overland Park, KS Overnight: Ascension Benefits & Insurance Solutions 9225 Indian Creek Parkway, Suite 700 Overland Park, KS QUESTIONS Call This brochure is for illustrative purposes only and is not a contract of insurance. You must refer to the actual policy for complete information regarding coverage terms, conditions and exclusions as they may change from one coverage period to the next. You may request a copy of the full policy by submitting a written request to us Summit 12/14

2 EXCLUSIONS The following represent only some of the exclusions contained in this policy. Abuse, molestation, harassment or sexual conduct Amusement devices (e.g.: rides, slides, inflatables, bungees, climbing walls, dunk tanks) Cryogenic chambers/therapy Cycling (other than stationary) Employment-related practices Instruction/activities held on or in open water (e.g.: lakes, ponds, ocean) Medical, therapy or health care services Operation, ownership or management of a fitness, dance or sports facility Physicals/stress testing Physical therapy, massage or salon services Sale or distribution of herbal medicinal and/or nutritional products Training programs for law enforcement, public safety and military personnel Those operations listed as ineligible Violation of statutes that govern s, faxes, phone calls or other methods of sending materials or information COVERAGES AND LIMITS Coverages Option 1 Option 2 Option 3 Option 4 Option 6 Commercial General Liability (CGL) Limits Limits Limits Limits Limits Each Occurrence $ 500,000 $ 1,000,000 $ 2,000,000 $ 3,000,000 $ 5,000,000 General Aggregate (Other than Products-completed Operations) $ 5,000,000 $ 5,000,000 $ 5,000,000 $ 5,000,000 $ 5,000,000 Products-completed Operations Aggregate $ 500,000 $ 1,000,000 $ 2,000,000 $ 3,000,000 $ 5,000,000 Personal and Advertising Injury $ 500,000 $ 1,000,000 $ 2,000,000 $ 3,000,000 $ 5,000,000 Legal Liability to Participants $ 500,000 $ 1,000,000 $ 2,000,000 $ 3,000,000 $ 5,000,000 Professional Liability $ 500,000 $ 1,000,000 $ 2,000,000 $ 3,000,000 $ 5,000,000 Damage to Premises Rented to You (Fire Legal Liability) $ 300,000 $ 300,000 $ 300,000 $ 300,000 $ 300,000 Medical Expense (other than participants) $ 5,000 $ 5,000 $ 5,000 $ 5,000 $ 5,000 Abuse, Molestation, Harassment or Sexual Conduct Defense Cost Reimbursement $ 100,000 $ 100,000 $ 100,000 $ 100,000 $ 100,000 Premiums: Certified Instructor - 1 year $ $ $ $ $ 1, Certified Instructor - 2 years $ $ $ Not Available Not Available Non-Certified Instructor - 1 year $ $ $ $ $ 1, Non-Certified Instructor - 2 years $ $ $ Not Available Not Available Refer to page 5 for $4,000,000 CGL premium rates (option 5) Coverage provided under this program includes: Commercial General Liability with Broadening Endorsement coverage which protects the insured against liability claims for bodily injury and property damage arising out of premises, operations, products and completed operations and personal and advertising injury. Legal Liability to Participants coverage which offers protection against bodily injury liability claims brought by persons participating in fitness/exercise activities under the direction of the insured. Professional Liability provides protection against wrongful acts (breach of duty, neglect, error, omission, misstatement or a misleading statement in the discharge of fitness/exercise activities) that occur under the operations of the insured. Abuse, Molestation, Harassment, or Sexual Conduct Defense Cost Reimbursement Although claims arising out of abuse, molestation, harassment or sexual conduct are excluded under this policy, this coverage (subject to the specific terms of this endorsement) reimburses you for up to $100,000 for defense costs resulting from abuse or molestation claims. Page 2 of 8

3 FREQUENTLY ASKED QUESTIONS 1. Can I apply for coverage over the phone? Unfortunately, we are not able to accept your enrollment information over the phone at this time. You can apply for coverage online or by completing an enrollment form and submitting it to us via , fax or mail. 2. What is a general aggregate? This is the maximum amount to be paid out in any policy period for all losses. 3. What types of fitness certifications are acceptable to obtain the premium discount? An acceptable certification or accreditation program is one that establishes standards and guidelines for the delivery of quality and professional fitness services as well as the development of ethic statements for fitness professionals. An individual will take a series of classes with testing at the end to become a certified professional in a fitness program. Normally to maintain certification yearly continuing education classes are required. A few examples of acceptable certifications are: AFAA, ACE, NAFTA, NASM, NESTA, ISSA, Cooper Institute, Yoga Alliance and Stott Pilates (SPX). 4. What are certificate requests? How do I complete this section on the enrollment form? A certificate is a document prepared by us providing you evidence of insurance. You will automatically receive a certificate providing proof of coverage once coverage is bound. You only need to complete the certificate request section if you have been asked to provide another certificate, to an entity such as the facility where you work. 5. I have been asked by the facility that I instruct at to add them as an additional insured to my policy. What does this mean and how do I do that? An additional insured is an entity which has an insurable interest for claims arising out of your negligence as the named insured. Such possible entities are a landlord or sponsor. By providing an entity additional insured status they now are entitled to defense and indemnity (if policy limits have not been exhausted) under your policy with no responsibility for premium payments. You can add an entity as an additional insured under the certificate request section of the enrollment form. Please remember to provide their complete name, address and relationship to you. All requests must be in writing. 6. I need $4,000,000 in CGL coverage. Is this option available? Yes. Please refer to page 5 for rates. 7. Will I receive a policy after I submit the enrollment form? No. You will receive a certificate of insurance as proof of coverage. Coverage is offered exclusively through Sports, Leisure and Entertainment Risk Purchasing Group (RPG). The RPG receives a master policy from the insurance company. Submission of this enrollment form confirms your desire to receive coverage through the RPG. Each member receives their own certificate of insurance as their evidence of coverage. The limits of insurance apply individually to each member there are no shared limits of liability with any other members. A copy of the RPG master policy can be requested in writing to: writing to: Ascension Benefits & Insurance Solutions, P.O. Box 25936, Overland Park, KS or programs@ascensionins.com. Page 3 of 8

4 Enrollment Form - Fitness Instructor Insurance Valid for effective dates from 1/1/16 through 12/31/16 Completion of this enrollment form confirms your desire to obtain insurance through the Sports, Leisure and Entertainment Risk Purchasing Group. An RPG provides group purchasing power for similar risks resulting in potential advantageous coverage terms, competitive rates, risk management bulletins, and rewards for favorable group loss experience. An RPG membership fee may be charged. The submission of this enrollment form and/or the acceptance of payment does not guarantee coverage. Certain operations are not eligible for coverage by this program. We reserve the right to decline any request for coverage. TO AVOID PROCESSING DELAYS, PLEASE: 1. Complete all sections (print legibly) 2. Sign and date where required 3. Remit completed enrollment form (pages 4-8) with payment m I am a new account m I am renewing my coverage GENERAL INFORMATION DATES Instructor s name (as it should appear on the policy): Doing business as (DBA): (additional name(s) under which the named insured operates) Mailing address: City: State: Zip: Phone: ( ) Cell: ( ) Fax: ( ) Website: Coverage will begin the day after the completed enrollment form and premium are received and approved by us, or on a later date you specify below. (If renewing coverage, please provide the expiration date of your current policy.) m Start my coverage on this date: / / 1. BUSINESS INFORMATION 1. Type of instructor (check all that apply): m Acro dance/tumbling m Acrobatic/partner yoga m Aerobics m Aerial/anti-gravity/ suspended yoga (certified instructor only) m Aquatic exercise m Cardio kickboxing m Children s fitness programs m Dance m Exercise m Fitness bootcamp m GYROTONIC m Hoop fitness m Personal training m Pilates m Qigong m Spinning m Strength m Tai chi m Tumbling (floor only, no gymnastic apparatus) m ZUMBA m Yoga 2. Are you age 18 or older? m Yes m No 3. Do you own or operate your own fitness or dance studio? m Yes m No (If yes, this program only provides coverage for your operations as an instructor. It does not extend to your employees or anyone performing instruction or training on your behalf, nor does it apply to the operation of a studio/facility) 4. Do you provide instruction of sports skills? m Yes m No (Sports skills instructors should apply for coverage through our Sports Instructor Insurance Program.) Coverage is not provided for an instructor s employment as an exempt or non-exempt employee of a school, university or college; for the coaching of organized competitive athletic teams; for activities of a certified athletic trainer; for instructors under the age of 18; and for instruction of sports skill activities. Ascension Benefits & Insurance Solutions P.O. Box Overland Park, KS = programs@ascensionins.com Fax Ascension Benefits & Insurance Solutions conducts business as Ascension Benefits and Insurance Solutions; in AK, AZ, CA, DC, HI, MT, NE, NV, NH, OK, SC, SD and WV as Ascension Benefits & Insurance Solutions Sports and Recreation; and in NY as Ascension Benefits Brokerage & Insurance Solutions Sports & Recreation. CA # , TX # Page 4 of 8

5 Please check the appropriate program and option: PROGRAM PREMIUM m I am a Certified instructor (certificate information must be provided) Certification organization: please check all that apply on page 6 Certification number and their expiration date(s): PREMIUM CERTIFIED Limits of 1 Year 2 - Years Options Liability (CGL) Premium Premium Option 1 $ 500,000 m $ m $ Option 2 $ 1,000,000 m $ m $ Option 3 $ 2,000,000 m $ m $ Option 4 $ 3,000,000 m $ Not Available Option 5 $ 4,000,000 m $ Not Available Option 6 $ 5,000,000 m $1, Not Available m I am a Non-certified Instructor PREMIUM NON-CERTIFIED Limits of 1 Year 2 - Years Options Liability (CGL) Premium Premium Option 1 $ 500,000 m $ m $ Option 2 $ 1,000,000 m $ m $ Option 3 $ 2,000,000 m $ m $ Option 4 $ 3,000,000 m $ Not Available Option 5 $ 4,000,000 m $ Not Available Option 6 $ 5,000,000 m $1, Not Available TOTAL COST SUMMARY Program Premium (from above) $ Risk Purchasing Group Membership Fee (required) $ Total Cost Due $ CERTIFICATE REQUESTS You will receive a certificate showing evidence that coverage has been bound. Complete this section to request additional certificates. Provide separate requests for each additional certificate needed. Indicate the type of certificate that you are requesting: m Additional insured OR m Evidence of coverage Certificate holder/entity name: Mailing address: City: State: Zip: Relationship to you: m Owner/lessor of premises m Sponsor m Co-promoter Other than being named on the certificate as an additional insured or certificate holder, does the person or organization require any special wording or endorsements? m Yes m No If yes, check all that apply (Check your request carefully before submitting. The most common delay in certificate processing is caused by providing a partial or incorrect name and/or instructions). m Form CG2026 m Primary endorsement m Waiver of subrogation m Other (please explain): Date certificate needed by: / / Page 5 of 8

6 Certification Listing - please check those certifications that you currently hold: m 7 Centers Yoga Arts m AAAI m AABS m AAHRFFP m AAPTE m ABSolution m ACE m ACIM/CPTF m Accredited Fitness Related Degree m ACSM m AEA (if qualified) m AFAA m AFPA m AFTA m Amazing Athletes m American Ballet Theatre (ABT) m American Fitness Institute (AFI) m AMFPT m An Coimisium le Rinci Gaelacha m Army Physical Fitness Course m Arthur Murray m ASFA m ATA m Art of Strength-Kettleball m Balanced Body University m BASI Pilates m BFIT m Bikram s Yoga College of India m Body Access m Body Balance Movement Therapy m BTFA m Burdenko Method m Centerspace m Cerceau Hoop m Chi For Longevity m Child Light Yoga m Clinical Exercise Physilogist m Cooper Institute m Core Dynamics Pilates m Core Power Yoga m Corfit m Crossfit m CSCCa m Designing Bodies m Devalila Yoga Teacher Training m ECA m ECITS m ESA m Excel Pilates m Expert Rating m Fit Forever m FitLaunch m Fitness Firm m Fitness Institute International m Fitness Together m Fitour m Fitour Pilates m FRA m Franklin - Methode m FXP Fitness Page 6 of 8 m Group 4 Fitness m Gyrokinesis m GYROTONIC m GYROTONIC Sales Corp. m Health & Exercise Sciences Degree m Health Wellness & Fitness Professional m Healthy Me Cardio Kickboxing m HFI m Hoopnotica m IDEA m IFA m IFPA m IFTA m IM=X Pilates m Integral Yoga m International Pilates m INTRAFITT m ISCA m ISFTA m ISMA m ISSA m It s Yoga m IYANGNY/Iyengar Yoga m Johnny G Spinning m Karuna Yoga m Kinderdance m Kore Pilates m Kripalu Center for Yoga & Health m LesMills Body Flow m MadDog Spinning m Mind/Body Meditation m Momentum m NAFC m NAFP m NAFTA m NAHF m NASM m NATA m National Dance Council of America m National Institute of Health Science (NIHS) m National Institute of Preventive Medicine m NCCPT m NCEP m NCSF m NCSM m NDEITA m NESTA m NETA m NFPA m NFPT m NFTA m NGA m NHCA m NIA m NPTI m NSCA m NSPA m Parrillo Performance m Pavel Tsatsouline m Peak Pilates m Performing Arts - Dance Degree m Personal Trainer Program m PFIT m Physical Mind Institute m Pilates Academy International m Pilates Certifications Center Inc m Pilates Elite m Pilates Institute of Southern California m Pilates Method Alliance (PMA) m Pilates Santa Fe m Pilates Teacher Training Program m Pilates Training Institute m PIYo m PLC/Pilates Leadership Concepts m Polestar m Power Pilates m Powerhouse Pilates m Regeneration Institute of Pilates m Retrofit Pilates m Romana s Pilates m Royal Academy of Dance m Russian Kettlebell Challenge m S.S. & Company m Sal Anthony s Movement Salon m Scirion Institute of Exercise Physiology m SCW (Les Mills) m Senior Fitness Assoc. (SFA) m Sheppard Method m SMART m SPA m Spinning.com m Stott Pilates (SPX) m Synergy Fitness Professionals m Tae Bo m Tai Chi 24 m Tai Chi Teacher Training m Tai Chi Health m The Kundalini Research Institute m The Pilates Center m USA Boxing m USA Weightlifting m USISTD (US Imperial Society of Teachers for Dance) m USWFA m Vishwa Yoga Darsha Ashram m WFA (World Fitness Assoc.) m WITS m YMCA m Yoga Alliance m Yoga Fit m Yoga Institute m Yoga Works m Zumba m Other:

7 ( DOCUMENT DELIVERY You will receive a certificate showing evidence that coverage has been bound. This coverage document will be delivered via , unless otherwise indicated below. If you have an insurance agent, all documents will be delivered to your agent only. Please select only one option. m to: attn: (selecting this option confirms your consent for coverage documents to be delivered via ) m Fax to: attn: m Mail to: attn: AGENTS ONLY TO BE COMPLETED ONLY IF LICENSED INSURANCE AGENT IS SUBMITTING THIS FORM Agency name: Agency mailing address: City: State: Zip: Agent/contact name: Agency telephone: ( ) Agency fax: ( ) Agent/contact address: Tax I.D: COVERAGE EXCLUSIONS The following exclusions are contained in the commercial general liability coverage provided by this program: Abuse, molestation, harassment or sexual conduct; Aircraft/hot air balloon; Airport; Amusement devices (the ownership, operation, maintenance or use of: any mechanical or non-mechanical ride, slide, or water slide, any inflatable recreational device, any bungee operation or equipment, any vertical device or equipment used for climbing-either permanently affixed or temporarily erected, or dunk tank. Amusement devices do not include any video or computer games or any device that is specifically designed for the training or instruction of the activity for which you are enrolled); Animals (injury or death to, or injury, death or property damage caused by any animal owned, rented or hired by you); Any adult-themed parties/meetings/trips, included but not limited to parties/meetings/trips during which demonstration of products and/or services used in the adult entertainment industry takes place; Asbestos; Commercial general liability standard exclusions (CG /13 edition); Cryogenic chambers/therapy; Cycling (other than stationary); Employment-related practices; Fireworks; Fitness/exercise operations related in whole or part, to perform as an exotic dancer or any similar occupation in the adult entertainment industry; Fungi or bacteria; Haunted attractions; Instruction/activities held on or in open water; Lead; Medical, therapy or health care services; Nuclear energy liability; Operation, ownership or management of a fitness, dance or sports facility; Performers; Physicals/ stress testing; Physical therapy, massage or salon services; Rodeos; Saddle animals; Sale or distribution of medicinal, herbal and/or nutritional products; Snowmobile; Training programs for law enforcement, public safety and military personnel; Violation of statutes that govern s, faxes, phone calls or other methods of sending materials or information; Those operations listed as ineligible: Certified athletic trainers, Coaching of organized competitive athletic teams, Instructors under the age of 18, Instruction of sports skills activities, Instructor s employment as an exempt or non-exempt employee of a school, university or college. COSTS ARE 100% NON-REFUNDABLE ONCE COVERAGE BEGINS. COVERAGE IS CONTINGENT UPON RECEIPT OF PAYMENT. NO COVERAGE WILL BE DEEMED IN EFFECT UNTIL THE ACCURATE PAYMENT IS RECEIVED BY THE COMPANY OR THEIR REPRESENTATIVE. PAYMENT INFORMATION m Check: Please make check payable to Ascension Benefits & Insurance Solutions. Enclosed is check # for $ m Credit Card: If you are making your payment by credit/debit card, please complete the following: m VISA m MASTERCARD m AMERICAN EXPRESS Card number: CSC # (card security) code: Expiration date: I authorize Ascension Benefits & Insurance Solutions to charge my payment to my credit card in the amount of $ Print name (as on card): Cardholder signature: Page 7 of 8

8 GENERAL FRAUD STATEMENT WARRANTY STATEMENT FOR OFFICE USE ONLY Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK Any person knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only. Applicable in KS Any person who knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*.*applies in NY Only. Applicable in ME, TN, VA and WA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. I further acknowledge that I have reviewed all information provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided. Applicant or agent signature: READ AND SIGN Date: Printed name: Title: If an agent: Check here to acknowledge you are signing on behalf of the named insured. m UW Rec: / / Status: N R Broker: Y N Comm: % OPS Rec: / / GL Exp Policy #: /CP #: Exp Dates: / / to / / GL Option: Delivery: M F E Date: / / Pay Plan: Bill: AB AD CBG Opt Form: Comments: GL Policy #: /CP #: GL Prem: Eff Date: / / to / / Insured #: Page 8 of 8 Copyright 2015 K&K Insurance Group, Inc. All Rights Reserved.